Provider Demographics
NPI:1053760157
Name:WALLY, BRIAN R (DPT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:WALLY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 417594
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-7594
Mailing Address - Country:US
Mailing Address - Phone:914-294-4050
Mailing Address - Fax:207-799-9340
Practice Address - Street 1:2520 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4250
Practice Address - Country:US
Practice Address - Phone:860-430-8383
Practice Address - Fax:860-856-6945
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT4733225100000X
CT011339225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist